Provider Demographics
NPI:1487721445
Name:LEOCADIO B PENALOSA JR
Entity type:Organization
Organization Name:LEOCADIO B PENALOSA JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEOCADIO
Authorized Official - Middle Name:B
Authorized Official - Last Name:PENALOSA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:757-397-5301
Mailing Address - Street 1:301 GOODE WAY
Mailing Address - Street 2:STE 204
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704
Mailing Address - Country:US
Mailing Address - Phone:757-397-5301
Mailing Address - Fax:757-397-9536
Practice Address - Street 1:301 GOODE WAY
Practice Address - Street 2:STE 204
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704
Practice Address - Country:US
Practice Address - Phone:757-397-5301
Practice Address - Fax:757-397-9536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty